1063635639 NPI number — COMMUNITY INNOVATIONS,INC.

Table of content: (NPI 1063635639)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063635639 NPI number — COMMUNITY INNOVATIONS,INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY INNOVATIONS,INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063635639
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2003 GODWIN AVE
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
LUMBERTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28358-3197
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-739-8849
Provider Business Mailing Address Fax Number:
910-739-5167

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2209 CENTURY DR
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27612-3941
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-786-4944
Provider Business Practice Location Address Fax Number:
919-786-4945
Provider Enumeration Date:
04/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
ANDY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
910-739-8849

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8301839B , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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